<?xml version="1.0" encoding="UTF-8"?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en" lang="en">
  <head>
    <title>修改病人风险评估表</title>
    <meta http-equiv="keywords" content="enter,your,keywords,here" />
    <meta http-equiv="description" content="A short description of this page." />
    <meta http-equiv="content-type" content="text/html; charset=UTF-8" />
    <#include "/template/head.html">
    <script type="text/javascript" src="${basePath}js/jquery.area.js" charset="utf-8"></script>
    <script type="text/javascript"> 
    $.metadata.setType("attr", "validate");
    $(document).ready(function() {
      $("#fxpgbForm").validate();
      $().area({xmlPath:"${basePath}Area.xml", defaultProvince:"${fxpgb.part1?if_exists.province}", defaultCity: "${fxpgb.part1?if_exists.city}", defaultCountry: "${fxpgb.part1?if_exists.country}"});
      rotDis('part1.fy', 'checked', [1], 'tb_fy_detail');
      rotDis('part1.atSchool', 'checked', [1], 'school_warp');
      rotDis('part1.worked', 'checked', [1], 'tb_worked_detail');
      rotDis('part1.worked', 'checked', [0], 'tb_unworked_detail');
      rotDis('part1.jls', 'checked', [1], 'tb_jls_detail');
      rotDis('part1.jail', 'checked', [1], 'tb_jail_detail');
      rotDis('part2.liveat', 'selected', ['家里', '集体宿舍', '宾馆或出租房', '其它'], 'liveat_warp');
      rotDis('part3.contact', 'checked', [1], 'tb_contact_detail');
      rotDis('part3.travel', 'checked', [1], 'tb_travel_detail');
      rotDis('part3.tvlReason', 'selected', ['其它'], 'trr_warp');
      rotDis('part3.place', 'checked', [1], 'tb_place_detail');
      rotDis('part3.bar', 'checked', [1], 'bar_warp');
      rotDis('part3.restaurant', 'checked', [1], 'ctt_warp');
      rotDis('part3.market', 'checked', [1], 'market_warp');
      rotDis('part3.hospital', 'checked', [1], 'hospital_warp');
      rotDis('part3.otherPlace', 'checked', [1], 'otherPlace_warp');
      rotDis('part4.havesf', 'checked', [1], 'havesf_warp');
      rotDis('part4.smoker', 'checked', [1], 'tb_smoker_detail');
      rotDis('part4.drinking', 'checked', [1], 'tb_drinking_detail');
      rotDis('part5.contactTB', 'checked', [1], 'tb_contactTB_detail');
      rotDis('part5.contactBlood', 'checked', [1], 'tb_contactBlood_detail');
      rotDis('part5.physicalExam', 'checked', [1], 'examOrg_warp');
      rotDis('part6.zxss', 'checked', [1], 'zxsslx_warp');
      rotDis('part6.qtss', 'checked', [1], 'qtsslx_warp');
      rotDis('part6.ws', 'checked', [1], 'wslx_warp');
    });
    </script> 
  </head>
  <body>
  <#macro chkSelect status val="null">
    <#if val!="null" && val==status>selected="selected"</#if>
  </#macro>
  <#macro chk_true val="null">
    <#if val!="null" && val>checked="checked"</#if>
  </#macro>
  <#macro chk_false val="null">
    <#if val!="null" && !val>checked="checked"</#if>
  </#macro>
    <form id="fxpgbForm" action="${basePath}brxx/update.do" method="post">
      <table class="cmxform" cellspacing="1">
        <caption>修&nbsp;&nbsp;改&nbsp;&nbsp;病&nbsp;&nbsp;人&nbsp;&nbsp;风&nbsp;&nbsp;险&nbsp;&nbsp;评&nbsp;&nbsp;估&nbsp;&nbsp;表</caption>
        <tr>
          <th width="12%">KICID号：</th>
          <td width="38%"><input name="kicid" value="${baseInfo.kicid}" class="disabled" readonly/></td>
          <th width="12%">病人姓名：</th>
          <td width="38%"><input name="brxm" value="${baseInfo.brxm}" class="disabled" readonly/></td>
        </tr>
        <tr>
          <th>访视者：</th>
          <td><input name="fszxm" value="${fxpgb.fszxm}" /></td>
          <th>填表日期：</th>
          <td><input id="tbrq" name="tbrq" value="${fxpgb.tbrq}" class="Wdate required date" /></td>
        </tr>
        <tr>
          <td colspan="4">
            <span style="color:blue">本表填写说明：日期格式 yyyy-MM-dd；</span>
            <br /> 一、病人基本情况
          </td>
        </tr>
        <#if fxpgb.part1??>
        <#assign part1=fxpgb.part1 />
        <tr>
          <th>出生地：</th>
          <td colspan="3">
            <select id="provinceId" name="part1.province">
              <option value="" selected="selected">省/直辖市</option>
            </select>
            <select id="cityId" name="part1.city">
              <option value="" selected="selected">请选择</option>
            </select>
            <select id="countryId" name="part1.country">
              <option value="" selected="selected">请选择</option>
            </select>
            <span id="qrsdrq_warp">
              <label for="part1.qrsdrq">若不是山东地区出生，何时迁入：</label>
              <input name="part1.qrsdrq" class="Wdate date" value="${part1.qrsdrq}"/>
            </span>
          </td>
        </tr>
        <tr>
          <th>是否曾在军队服役：</th>
          <td colspan="3">
            <span onclick="rotDis('part1.fy', 'checked', [1], 'tb_fy_detail')">
              <input type="radio" name="part1.fy" value="1" <#if fxpgb.part1.fy?? && fxpgb.part1.fy==1>checked</#if> class="required"/>是
              <input type="radio" name="part1.fy" value="2" <#if fxpgb.part1.fy?? && fxpgb.part1.fy==2>checked</#if>/>否
              <input type="radio" name="part1.fy" value="3" <#if fxpgb.part1.fy?? && fxpgb.part1.fy==3>checked</#if>/>不详
              <label for="part1.fy" class="error">*</label>
            </span>
            <table id="tb_fy_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="12%">何时服役：</th>
                <td width="38%">从 <input name="part1.fyqs" disabled="disabled" value="${part1.fyqs}" class="w60 number"/> 年至  <input name="part1.fyjz" disabled="disabled" value="${part1.fyjz}" class="w60 number"/></td>
                <th width="12%">何处服役：</th>
                <td width="38%"><input name="part1.fyaddr" value="${part1.fyaddr}" disabled="disabled"/></td>
              </tr>
            </table>
          </td>
        </tr>
        <tr>
          <th>当前婚姻状况：</th>
          <td>
            <select name="part1.hyzk" class="required">
              <option value=""></option>
              <#list constants.hyzk as item>
              <option value="${item_index+1}" <@chkSelect status=item_index+1 val=fxpgb.part1.hyzk/>>${item}</option>
              </#list>
            </select><label for="part1.hyzk" class="error">*</label>
          </td>
          <th>出现症状前或者出现症状时的居住地：</th>
          <td>
            <input name="part1.hbaddr" value="${part1.hbaddr}" />
          </td>
        </tr>
        <tr>
          <th>接受了多少年的教育：</th>
          <td colspan="3">
            <input name="part1.jynx" value="${part1.jynx}" class="number"/> 年
            <label for="atSchool">目前是否仍在校？</label>
            <span onclick="rotDis('part1.atSchool', 'checked', [1], 'school_warp')">
              <input type="radio" name="part1.atSchool" value="1" <@chk_true val=part1.atSchool/> class="required"/>是
              <input type="radio" name="part1.atSchool" value="0" <@chk_false val=part1.atSchool/>/>否
              <label for="part1.atSchool" class="error">*</label>
            </span>
            <span id="school_warp" class="none">
              <label for="part1.school">学校名称：</label>
              <input name="part1.school" value="${part1.school}" disabled="disabled"/>
            </span>
          </td>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>你目前（在患病/有症状/就医的3个月内）是否在工作或做临时工：</label>
            <span onclick="rotDis('part1.worked', 'checked', [1], 'tb_worked_detail');rotDis('part1.worked', 'checked', [0], 'tb_unworked_detail')">
              <input type="radio" name="part1.worked" value="1" <@chk_true val=part1.worked/> class="required"/>是
              <input type="radio" name="part1.worked" value="0" <@chk_false val=part1.worked/>/>否
              <label for="part1.worked" class="error">*</label>
            </span>
            <table id="tb_worked_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">你最近的职业是什么：</th>
                <td width="80%">
                  <input name="part1.zjzy" value="${part1.zjzy}" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">工作场所位置（地址或街道）：</th>
                <td width="80%">
                  <input name="part1.gzcs" value="${part1.gzcs}" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你在这里工作了多长时间：</th>
                <td width="80%">
                  <input name="part1.gzsj" value="${part1.gzsj}" disabled="disabled"/>
                </td>
              </tr>
            </table>
            <table id="tb_unworked_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">最近一次被雇佣的时间：</th>
                <td width="80%">
                  <input name="part1.zjgzrq" value="${part1.zjgzrq}" disabled="disabled" class="Wdate date"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你是否退休/伤残或未就业5年以上：</th>
                <td width="80%">
                  <input name="part1.wgz5n" type="radio" value="1" <@chk_true val=part1.wgz5n/> disabled="disabled"/>是
                  <input name="part1.wgz5n" type="radio" value="0" <@chk_false val=part1.wgz5n/> disabled="disabled"/>否
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是否曾经待过拘留所：</label>
            <span onclick="rotDis('part1.jls', 'checked', [1], 'tb_jls_detail')">
              <input type="radio" name="part1.jls" value="1" <@chk_true val=part1.jls/> class="required"/>是
              <input type="radio" name="part1.jls" value="0" <@chk_false val=part1.jls/>/>否
              <label for="part1.jls" class="error">*</label>
            </span>
            <table id="tb_jls_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">你是什么时间进的拘留所：</th>
                <td width="80%">
                  <input name="part1.jlsrq" value="${part1.jlsrq}" disabled="disabled" class="Wdate date"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你总共在拘留所中待了多长时间：</th>
                <td width="80%">
                  <input name="part1.jlssc" value="${part1.jlssc}" disabled="disabled" class="number"/> 月
                </td>
              </tr>
              <tr>
                <th width="20%">拘留所在何处：</th>
                <td width="80%">
                  <input name="part1.jlsaddr" value="${part1.jlsaddr}" disabled="disabled"/>（详细名称和位置）
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是否曾经待过监狱：</label>
            <span onclick="rotDis('part1.jail', 'checked', [1], 'tb_jail_detail')">
              <input type="radio" name="part1.jail" value="1" <@chk_true val=part1.jail/> class="required"/>是
              <input type="radio" name="part1.jail" value="0" <@chk_false val=part1.jail/>/>否
              <label for="part1.jail" class="error">*</label>
            </span>
            <table id="tb_jail_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">你是什么时间进的监狱：</th>
                <td width="80%">
                  <input name="part1.jailrq" value="${part1.jailrq}" disabled="disabled" class="Wdate date"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你总共在监狱中待了多长时间：</th>
                <td width="80%">
                  <input name="part1.jailsc" value="${part1.jailsc}" disabled="disabled" class="number"/> 月
                </td>
              </tr>
              <tr>
                <th width="20%">监狱在何处：</th>
                <td width="80%">
                  <input name="part1.jailaddr" value="${part1.jailaddr}" disabled="disabled"/>（详细名称和位置）
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <#else>
        <tr>
          <td colspan="4">
            <span style="color:blue">本表填写说明：日期格式 yyyy-MM-dd；</span>
            <br /> 一、病人基本情况
          </td>
        </tr>
        <tr>
          <th>出生地：</th>
          <td colspan="3">
            <select id="provinceId" name="part1.province" onchange="area.onSelectCity();">
              <option value="" selected="selected">省/直辖市</option>
            </select>
            <select id="cityId" name="part1.city" onchange="area.onSelectCountry();">
              <option value="" selected="selected">请选择</option>
            </select>
            <select id="countryId" name="part1.country">
              <option value="" selected="selected">请选择</option>
            </select>
            <span id="qrsdrq_warp">
              <label for="part1.qrsdrq">若不是山东地区出生，何时迁入：</label>
              <input name="part1.qrsdrq" class="Wdate date"/>
            </span>
          </td>
        </tr>
        <tr>
          <th>是否曾在军队服役：</th>
          <td colspan="3">
            <span onclick="rotDis('part1.fy', 'checked', [1], 'tb_fy_detail')">
              <input type="radio" name="part1.fy" value="1" class="required"/>是
              <input type="radio" name="part1.fy" value="2"/>否
              <input type="radio" name="part1.fy" value="3"/>不详
              <label for="part1.fy" class="error">*</label>
            </span>
            <table id="tb_fy_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="12%">何时服役：</th>
                <td width="38%">从 <input name="part1.fyqs" disabled="disabled" class="w60 number"/> 年至  <input name="part1.fyjz" disabled="disabled" class="w60 number"/></td>
                <th width="12%">何处服役：</th>
                <td width="38%"><input name="part1.fyaddr" disabled="disabled"/></td>
              </tr>
            </table>
          </td>
        </tr>
        <tr>
          <th>当前婚姻状况：</th>
          <td>
            <select name="part1.hyzk" class="required">
              <option value=""></option>
              <#list constants.hyzk as item>
              <option value="${item_index+1}">${item}</option>
              </#list>
            </select>
          </td>
          <th>出现症状前或者出现症状时的居住地：</th>
          <td>
            <input name="part1.hbaddr" />
          </td>
        </tr>
        <tr>
          <th>接受了多少年的教育：</th>
          <td colspan="3">
            <input name="part1.jynx" class="number"/> 年
            <label for="atSchool">目前是否仍在校？</label>
            <span onclick="rotDis('part1.atSchool', 'checked', [1], 'school_warp')">
              <input type="radio" name="part1.atSchool" value="1" class="required"/>是
              <input type="radio" name="part1.atSchool" value="0"/>否
              <label for="part1.atSchool" class="error">*</label>
            </span>
            <span id="school_warp" class="none">
              <label for="part1.school">学校名称：</label>
              <input name="part1.school" disabled="disabled"/>
            </span>
          </td>
        </tr>
        <tr>
          <th colspan="4" class="indent2em left">
            <label>你目前（在患病/有症状/就医的3个月内）是否在工作或做临时工：</label>
            <span onclick="rotDis('part1.worked', 'checked', [1], 'tb_worked_detail');rotDis('part1.worked', 'checked', [0], 'tb_unworked_detail')">
              <input type="radio" name="part1.worked" value="1" class="required"/>是
              <input type="radio" name="part1.worked" value="0"/>否
              <label for="part1.worked" class="error">*</label>
            </span>
            <table id="tb_worked_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">你最近的职业是什么：</th>
                <td width="80%">
                  <input name="part1.zjzy" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">工作场所位置（地址或街道）：</th>
                <td width="80%">
                  <input name="part1.gzcs" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你在这里工作了多长时间：</th>
                <td width="80%">
                  <input name="part1.gzsj" disabled="disabled"/>
                </td>
              </tr>
            </table>
            <table id="tb_unworked_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">最近一次被雇佣的时间：</th>
                <td width="80%">
                  <input name="part1.zjgzrq" disabled="disabled" class="Wdate date"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你是否退休/伤残或未就业5年以上：</th>
                <td width="80%">
                  <input name="part1.wgz5n" type="radio" value="1" disabled="disabled"/>是
                  <input name="part1.wgz5n" type="radio" value="0" disabled="disabled"/>否
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是否曾经待过拘留所：</label>
            <span onclick="rotDis('part1.jls', 'checked', [1], 'tb_jls_detail')">
              <input type="radio" name="part1.jls" value="1" class="required"/>是
              <input type="radio" name="part1.jls" value="0"/>否
              <label for="part1.jls" class="error">*</label>
            </span>
            <table id="tb_jls_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">你是什么时间进的拘留所：</th>
                <td width="80%">
                  <input name="part1.jlsrq" disabled="disabled" class="Wdate date"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你总共在拘留所中待了多长时间：</th>
                <td width="80%">
                  <input name="part1.jlssc" disabled="disabled" class="number"/> 月
                </td>
              </tr>
              <tr>
                <th width="20%">拘留所在何处：</th>
                <td width="80%">
                  <input name="part1.jlsaddr" disabled="disabled"/>（详细名称和位置）
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是否曾经待过监狱：</label>
            <span onclick="rotDis('part1.jail', 'checked', [1], 'tb_jail_detail')">
              <input type="radio" name="part1.jail" value="1" class="required"/>是
              <input type="radio" name="part1.jail" value="0"/>否
              <label for="part1.jail" class="error">*</label>
            </span>
            <table id="tb_jail_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">你是什么时间进的监狱：</th>
                <td width="80%">
                  <input name="part1.jailrq" disabled="disabled" class="Wdate date"/>
                </td>
              </tr>
              <tr>
                <th width="20%">你总共在监狱中待了多长时间：</th>
                <td width="80%">
                  <input name="part1.jailsc" disabled="disabled" class="number"/> 月
                </td>
              </tr>
              <tr>
                <th width="20%">监狱在何处：</th>
                <td width="80%">
                  <input name="part1.jailaddr" disabled="disabled"/>（详细名称和位置）
                </td>
              </tr>
            </table>
          </th>
        </tr>
        </#if>
        <tr>
          <td colspan="4">二、病人生活情况</td>
        </tr>
        <#if fxpgb.part2??>
        <#assign part2=fxpgb.part2/>
        <tr>
          <th>目前生活在哪里：</th>
          <td colspan="3">
            <select name="part2.liveat" onchange="rotDis('part2.liveat', 'selected', ['家里', '集体宿舍', '宾馆或出租房', '其它'], 'liveat_warp')">
              <option value=""></option>
              <#list constants.liveat as item>
              <option value="${item_index+1}" <@chkSelect status=item_index+1 val=part2.liveat />>${item}</option>
              </#list>
            </select>
            <br />
            <span id="liveat_warp" class="none">
              <label for="part2.liveTime">居住了多长时间？</label>
              <input name="part2.liveTime" value="${part2.liveTime}" disabled="disabled"/>
              <label for="part2.liveAddr">（详细名称和位置）</label>
              <input name="part2.liveAddr" value="${part2.liveAddr}" disabled="disabled"/>
            </span>
          </td>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>包括你本人共有多少成人/儿童住在那里？</label>
            <input name="part2.numberOfAdults" value="${part2.numberOfAdults}" class="w60 number"/>（成人＞=18岁）
            <input name="part2.numberOfChildren" value="${part2.numberOfChildren}" class="w60 number"/>（儿童＜18岁）
            <label>家里共有多少间？</label><input name="part2.numberOfRoom" value="${part2.numberOfRoom}" class="w60 number"/>
          </th>
        </tr>
        <tr>
          <th>家庭年总收入：</th>
          <td colspan="3">
            <select name="part2.income">
              <option value=""></option>
              <#list constants.income as item>
              <option value="${item_index+1}" <@chkSelect status=item_index+1 val=fxpgb.part2?if_exists.income/>>${item}</option>
              </#list>
            </select>
          </td>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>请给出了解你情况的联系人（如母亲或亲属）的名字和电话：</label><br />
            <label>详细名称</label><input name="part2.relative" value="${part2.relative}"/>
            <label>亲属关系</label><input name="part2.relationship" value="${part2.relationship}"/>
            <label>电话号码</label><input name="part2.relativeTel" value="${part2.relativeTel}"/>
          </th>
        </tr>
        <#else>
        <tr>
          <th>目前生活在哪里：</th>
          <td colspan="3">
            <select name="part2.liveat" onchange="rotDis('part2.liveat', 'selected', ['家里', '集体宿舍', '宾馆或出租房', '其它'], 'liveat_warp')">
              <option value=""></option>
              <#list constants.liveat as item>
              <option value="${item_index+1}">${item}</option>
              </#list>
            </select>
            <br />
            <span id="liveat_warp" class="none">
              <label for="part2.liveTime">居住了多长时间？</label>
              <input name="part2.liveTime" disabled="disabled"/>
              <label for="part2.liveAddr">（详细名称和位置）</label>
              <input name="part2.liveAddr" disabled="disabled"/>
            </span>
          </td>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>包括你本人共有多少成人/儿童住在那里？</label>
            <input name="part2.numberOfAdults" class="w60 number"/>（成人＞=18岁）
            <input name="part2.numberOfChildren" class="w60 number"/>（儿童＜18岁）
            <label>家里共有多少间？</label><input name="part2.numberOfRoom" class="w60 number"/>
          </th>
        </tr>
        <tr>
          <th>家庭年总收入：</th>
          <td colspan="3">
            <select name="part2.income">
              <option value=""></option>
              <#list constants.income as item>
              <option value="${item_index+1}">${item}</option>
              </#list>
            </select>
          </td>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>请给出了解你情况的联系人（如母亲或亲属）的名字和电话：</label><br />
            <label>详细名称</label><input name="part2.relative"/>
            <label>亲属关系</label><input name="part2.relationship"/>
            <label>电话号码</label><input name="part2.relativeTel"/>
          </th>
        </tr>
        </#if>
        <tr>
          <td colspan="4">三、旅行和社会接触</td>
        </tr>
        <#if fxpgb.part3??>
        <#assign part3=fxpgb.part3/>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>在你有症状之前2年内，是否曾与临时来山东的亲属、朋友有过任何接触：</label>
            <span onclick="rotDis('part3.contact', 'checked', [1], 'tb_contact_detail')">
              <input type="radio" name="part3.contact" value="1" <@chk_true val=part3.contact/>/>是
              <input type="radio" name="part3.contact" value="0" <@chk_false val=part3.contact/>/>否
            </span>
            <table id="tb_contact_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">接触人姓名：</th>
                <td width="80%">
                  <input name="part3.cttPeople" value="${part3.cttPeople}" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">地点（详细名称和地址）：</th>
                <td width="80%">
                  <input name="part3.cttAddr" value="${part3.cttAddr}" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">亲属关系：</th>
                <td width="80%">
                  <input name="part3.cttRelationship" value="${part3.cttRelationship}" disabled="disabled"/>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>在你有症状之前6个月内，你是否曾到山东之外旅游：</label>
            <span onclick="rotDis('part3.travel', 'checked', [1], 'tb_travel_detail')">
              <input type="radio" name="part3.travel" value="1" <@chk_true val=part3.travel/>/>是
              <input type="radio" name="part3.travel" value="0" <@chk_false val=part3.travel/>/>否
            </span>
            <table id="tb_travel_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">共有多少次旅游：</th>
                <td width="80%">
                  <input name="part3.tvlTimes" value="${part3.tvlTimes}" disabled="disabled" class="number"/> 次
                </td>
              </tr>
              <tr>
                <th width="20%">最后一次到何处：</th>
                <td width="80%">
                  <input name="part3.lastTvlAddr" value="${part3.lastTvlAddr}" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">在那里停留了多长时间：</th>
                <td width="80%">
                  <input name="part3.tvlStayDays" value="${part3.tvlStayDays}" disabled="disabled" class="number"/> 天
                </td>
              </tr>
              <tr>
                <th width="20%">此次旅游的原因：</th>
                <td width="80%">
                  <select name="part3.tvlReason" disabled="disabled" onchange="rotDis('part3.tvlReason', 'selected', ['其它'], 'trr_warp')">
                    <option value=""></option>
                    <#list constants.tvlreason as item>
                    <option value="${item_index+1}" <@chkSelect status=item_index+1 val=part3.tvlReason/>>${item}</option>
                    </#list>
                  </select>
                  <span id="trr_warp" class="none">
                    <label for="part3.tvlReasonRemark">注明</label>
                    <input name="part3.tvlReasonRemark" value="${part3.tvlReasonRemark}" disabled="disabled"/>
                  </span>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>除家庭、学校或工作单位之外，是否还有你每周去过2次以上的地方：</label>
            <span onclick="rotDis('part3.place', 'checked', [1], 'tb_place_detail')">
              <input type="radio" name="part3.place" value="1" <@chk_true val=part3.place/>/>是
              <input type="radio" name="part3.place" value="0" <@chk_false val=part3.place/>/>否
            </span>
            <table id="tb_place_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">
                  <label>酒吧</label>
                  <input type="checkbox" name="part3.bar" value="1" <@chk_true val=part3.bar/> disabled="disabled" onclick="rotDis('part3.bar', 'checked', [1], 'bar_warp')"/>
                </th>
                <td width="80%">
                  <span id="bar_warp" class="none">
                    <label>名称：</label><input name="part3.barName" value="${part3.barName}" disabled="disabled"/>
                    <label>位置：</label><input name="part3.barAddr" value="${part3.barAddr}" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>餐馆或其它饮食店</label>
                  <input type="checkbox" name="part3.restaurant" value="1" <@chk_true val=part3.restaurant/> disabled="disabled" onclick="rotDis('part3.restaurant', 'checked', [1], 'ctt_warp')"/>
                </th>
                <td>
                  <span id="ctt_warp" class="none">
                    <label>名称：</label><input name="part3.rttName" value="${part3.rttName}" disabled="disabled"/>
                    <label>位置：</label><input name="part3.rttAddr" value="${part3.rttAddr}" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>农贸市场或集市</label>
                  <input type="checkbox" name="part3.market" value="1" <@chk_true val=part3.market/> disabled="disabled" onclick="rotDis('part3.market', 'checked', [1], 'market_warp')"/>
                </th>
                <td>
                  <span id="market_warp" class="none">
                    <label>名称：</label><input name="part3.marketName" value="${part3.marketName}" disabled="disabled"/>
                    <label>位置：</label><input name="part3.marketAddr" value="${part3.marketAddr}" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>诊所或医院</label>
                  <input type="checkbox" name="part3.hospital" value="1" <@chk_true val=part3.hospital/> disabled="disabled" onclick="rotDis('part3.hospital', 'checked', [1], 'hospital_warp')"/>
                </th>
                <td>
                  <span id="hospital_warp" class="none">
                    <label>名称：</label><input name="part3.hospitalName" value="${part3.hospitalName}" disabled="disabled"/>
                    <label>位置：</label><input name="part3.hospitalAddr" value="${part3.hospitalAddr}" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>另外常去地方</label>
                  <input type="checkbox" name="part3.otherPlace" value="1" <@chk_true val=part3.otherPlace/> disabled="disabled" onclick="rotDis('part3.otherPlace', 'checked', [1], 'otherPlace_warp')"/>
                </th>
                <td>
                  <span id="otherPlace_warp" class="none">
                    <label>名称：</label><input name="part3.otherPlaceName" value="${part3.otherPlaceName}" disabled="disabled"/>
                    <label>位置：</label><input name="part3.otherPlaceAddr" value="${part3.otherPlaceAddr}" disabled="disabled"/>
                  </span>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <#else>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>在你有症状之前2年内，是否曾与临时来山东的亲属、朋友有过任何接触：</label>
            <span onclick="rotDis('part3.contact', 'checked', [1], 'tb_contact_detail')">
              <input type="radio" name="part3.contact" value="1"/>是
              <input type="radio" name="part3.contact" value="0"/>否
            </span>
            <table id="tb_contact_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">接触人姓名：</th>
                <td width="80%">
                  <input name="part3.cttPeople" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">地点（详细名称和地址）：</th>
                <td width="80%">
                  <input name="part3.cttAddr" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">亲属关系：</th>
                <td width="80%">
                  <input name="part3.cttRelationship" disabled="disabled"/>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>在你有症状之前6个月内，你是否曾到山东之外旅游：</label>
            <span onclick="rotDis('part3.travel', 'checked', [1], 'tb_travel_detail')">
              <input type="radio" name="part3.travel" value="1"/>是
              <input type="radio" name="part3.travel" value="0"/>否
            </span>
            <table id="tb_travel_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">共有多少次旅游：</th>
                <td width="80%">
                  <input name="part3.tvlTimes" disabled="disabled" class="number"/> 次
                </td>
              </tr>
              <tr>
                <th width="20%">最后一次到何处：</th>
                <td width="80%">
                  <input name="part3.lastTvlAddr" disabled="disabled"/>
                </td>
              </tr>
              <tr>
                <th width="20%">在那里停留了多长时间：</th>
                <td width="80%">
                  <input name="part3.tvlStayDays" disabled="disabled" class="number"/> 天
                </td>
              </tr>
              <tr>
                <th width="20%">此次旅游的原因：</th>
                <td width="80%">
                  <select name="part3.tvlReason" disabled="disabled" onchange="rotDis('part3.tvlReason', 'selected', ['其它'], 'trr_warp')">
                    <option value=""></option>
                    <#list constants.tvlreason as item>
                    <option value="${item_index+1}">${item}</option>
                    </#list>
                  </select>
                  <span id="trr_warp" class="none">
                    <label for="part3.tvlReasonRemark">注明</label>
                    <input name="part3.tvlReasonRemark" disabled="disabled"/>
                  </span>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>除家庭、学校或工作单位之外，是否还有你每周去过2次以上的地方：</label>
            <span onclick="rotDis('part3.place', 'checked', [1], 'tb_place_detail')">
              <input type="radio" name="part3.place" value="1"/>是
              <input type="radio" name="part3.place" value="0"/>否
            </span>
            <table id="tb_place_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">
                  <label>酒吧</label>
                  <input type="checkbox" name="part3.bar" value="1" disabled="disabled" onclick="rotDis('part3.bar', 'checked', [1], 'bar_warp')"/>
                </th>
                <td width="80%">
                  <span id="bar_warp" class="none">
                    <label>名称：</label><input name="part3.barName" disabled="disabled"/>
                    <label>位置：</label><input name="part3.barAddr" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>餐馆或其它饮食店</label>
                  <input type="checkbox" name="part3.restaurant" value="1" disabled="disabled" onclick="rotDis('part3.restaurant', 'checked', [1], 'ctt_warp')"/>
                </th>
                <td>
                  <span id="ctt_warp" class="none">
                    <label>名称：</label><input name="part3.rttName" disabled="disabled"/>
                    <label>位置：</label><input name="part3.rttAddr" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>农贸市场或集市</label>
                  <input type="checkbox" name="part3.market" value="1" disabled="disabled" onclick="rotDis('part3.market', 'checked', [1], 'market_warp')"/>
                </th>
                <td>
                  <span id="market_warp" class="none">
                    <label>名称：</label><input name="part3.marketName" disabled="disabled"/>
                    <label>位置：</label><input name="part3.marketAddr" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>诊所或医院</label>
                  <input type="checkbox" name="part3.hospital" value="1" disabled="disabled" onclick="rotDis('part3.hospital', 'checked', [1], 'hospital_warp')"/>
                </th>
                <td>
                  <span id="hospital_warp" class="none">
                    <label>名称：</label><input name="part3.hospitalName" disabled="disabled"/>
                    <label>位置：</label><input name="part3.hospitalAddr" disabled="disabled"/>
                  </span>
                </td>
              </tr>
              <tr>
                <th>
                  <label>另外常去地方</label>
                  <input type="checkbox" name="part3.otherPlace" value="1" disabled="disabled" onclick="rotDis('part3.otherPlace', 'checked', [1], 'otherPlace_warp')"/>
                </th>
                <td>
                  <span id="otherPlace_warp" class="none">
                    <label>名称：</label><input name="part3.otherPlaceName" disabled="disabled"/>
                    <label>位置：</label><input name="part3.otherPlaceAddr" disabled="disabled"/>
                  </span>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        </#if>
        <tr>
          <td colspan="4">四、烟草/酒精接触史</td>
        </tr>
        <#if fxpgb.part4??>
        <#assign part4=fxpgb.part4/>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>在与您同住的人中是否有人吸烟：</label>
            <span onclick="rotDis('part4.havesf', 'checked', [1], 'havesf_warp')">
              <input type="radio" name="part4.havesf" value="1" <@chk_true val=part4.havesf/>/>是
              <input type="radio" name="part4.havesf" value="0" <@chk_false val=part4.havesf/>/>否
            </span>
            <span id="havesf_warp" class="none">
              <label for="part4.numOfsf">吸烟人数</label>
              <input name="part4.numOfsf" value="${part4.numOfsf}" disabled="disabled" class="w40 number"/>
            </span>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是吸烟者吗：</label>
            <span onclick="rotDis('part4.smoker', 'checked', [1], 'tb_smoker_detail')">
              <input type="radio" name="part4.smoker" value="1" <@chk_true val=part4.smoker/>/>是
              <input type="radio" name="part4.smoker" value="0" <@chk_false val=part4.smoker/>/>否
            </span>
            <table id="tb_smoker_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">
                  <label>如何描述您的吸烟史：</label>
                </th>
                <td width="80%">
                  <input type="radio" name="part4.descOfSmoking" value="1" <#if part4.descOfSmoking?? && part4.descOfSmoking==1>checked</#if> disabled="disabled"/>以前吸烟
                  <input type="radio" name="part4.descOfSmoking" value="2" <#if part4.descOfSmoking?? && part4.descOfSmoking==2>checked</#if> disabled="disabled"/>当前吸烟
                </td>
              </tr>
              <tr>
                <th width="20%">
                  <label>您每天吸几包烟：</label>
                </th>
                <td width="80%">
                  <input name="part4.cigaret" value="${part4.cigaret}" disabled="disabled" class="number"/> 包/天
                </td>
              </tr>
              <tr>
                <th width="20%">
                  <label>您吸烟有多长时间：</label>
                </th>
                <td width="80%">
                  <input name="part4.smokingHistory" value="${part4.smokingHistory}" disabled="disabled"/>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>半年内是否饮酒</label>
            <span onclick="rotDis('part4.drinking', 'checked', [1], 'tb_drinking_detail')">
              <input type="radio" name="part4.drinking" value="1" <@chk_true val=part4.drinking/>/>是
              <input type="radio" name="part4.drinking" value="0" <@chk_false val=part4.drinking/>/>否
            </span>
            <table id="tb_drinking_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="30%">
                  <label>您引用含酒精饮料（啤酒、红酒、高度酒）的频度如何：</label>
                </th>
                <td width="70%">
                  <select name="part4.fqcOfDrinking" disabled="disabled">
                    <option value=""></option>
                    <#list constants.fqcOfDrinking as item>
                    <option value="${item_index+1}" <@chkSelect status=item_index+1 val=part4.fqcOfDrinking/>>${item}</option>
                    </#list>
                  </select>
                </td>
              </tr>
              <tr>
                <th><label>您在一天中经常喝多少（饮用数量和酒品种类）：</label></th>
                <td><input name="part4.drinkEachDay" value="${part4.drinkEachDay}" disabled="disabled"/></td>
              </tr>
              <tr>
                <th>
                  <label>您饮酒已经有多长时间了：</label>
                </th>
                <td>
                  <input name="part4.drinkingHistory" value="${part4.drinkingHistory}" disabled="disabled"/>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <#else>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>在与您同住的人中是否有人吸烟：</label>
            <span onclick="rotDis('part4.havesf', 'checked', [1], 'havesf_warp')">
              <input type="radio" name="part4.havesf" value="1"/>是
              <input type="radio" name="part4.havesf" value="0"/>否
            </span>
            <span id="havesf_warp" class="none">
              <label for="part4.numOfsf">吸烟人数</label>
              <input name="part4.numOfsf" disabled="disabled" class="w40 number"/>
            </span>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是吸烟者吗：</label>
            <span onclick="rotDis('part4.smoker', 'checked', [1], 'tb_smoker_detail')">
              <input type="radio" name="part4.smoker" value="1"/>是
              <input type="radio" name="part4.smoker" value="0"/>否
            </span>
            <table id="tb_smoker_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">
                  <label>如何描述您的吸烟史：</label>
                </th>
                <td width="80%">
                  <input type="radio" name="part4.descOfSmoking" value="1" disabled="disabled"/>以前吸烟
                  <input type="radio" name="part4.descOfSmoking" value="2" disabled="disabled"/>当前吸烟
                </td>
              </tr>
              <tr>
                <th width="20%">
                  <label>您每天吸几包烟：</label>
                </th>
                <td width="80%">
                  <input name="part4.cigaret" disabled="disabled" class="number"/> 包/天
                </td>
              </tr>
              <tr>
                <th width="20%">
                  <label>您吸烟有多长时间：</label>
                </th>
                <td width="80%">
                  <input name="part4.smokingHistory" disabled="disabled"/>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>半年内是否饮酒</label>
            <span onclick="rotDis('part4.drinking', 'checked', [1], 'tb_drinking_detail')">
              <input type="radio" name="part4.drinking" value="1"/>是
              <input type="radio" name="part4.drinking" value="0"/>否
            </span>
            <table id="tb_drinking_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="30%">
                  <label>您引用含酒精饮料（啤酒、红酒、高度酒）的频度如何：</label>
                </th>
                <td width="70%">
                  <select name="part4.fqcOfDrinking" disabled="disabled">
                    <option value=""></option>
                    <#list constants.fqcOfDrinking as item>
                    <option value="${item_index+1}">${item}</option>
                    </#list>
                  </select>
                </td>
              </tr>
              <tr>
                <th><label>您在一天中经常喝多少（饮用数量和酒品种类）：</label></th>
                <td><input name="part4.drinkEachDay" disabled="disabled"/></td>
              </tr>
              <tr>
                <th>
                  <label>您饮酒已经有多长时间了：</label>
                </th>
                <td>
                  <input name="part4.drinkingHistory" disabled="disabled"/>
                </td>
              </tr>
            </table>
          </th>
        </tr>
        </#if>
        <tr>
          <td colspan="4">五、病人医疗史</td>
        </tr>
        <#if fxpgb.part5??>
        <#assign part5=fxpgb.part5 />
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你过去是否曾被告知（诊断）患有结核病：</label>
            <input type="radio" name="part5.diagnosedAsTB" value="1" <#if part5.diagnosedAsTB?? && part5.diagnosedAsTB==1>checked</#if>/>是
            <input type="radio" name="part5.diagnosedAsTB" value="2" <#if part5.diagnosedAsTB?? && part5.diagnosedAsTB==2>checked</#if>/>否
            <input type="radio" name="part5.diagnosedAsTB" value="3" <#if part5.diagnosedAsTB?? && part5.diagnosedAsTB==3>checked</#if>/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是否与曾被告知（诊断）患有结核病的任何人有过接触（并非指强阳性结核菌素皮肤实验结果）</label>
            <span onclick="rotDis('part5.contactTB', 'checked', [1], 'tb_contactTB_detail')">
              <input type="radio" name="part5.contactTB" value="1" <#if part5.contactTB?? && part5.contactTB==1>checked</#if>/>是
              <input type="radio" name="part5.contactTB" value="2" <#if part5.contactTB?? && part5.contactTB==2>checked</#if>/>否
              <input type="radio" name="part5.contactTB" value="3" <#if part5.contactTB?? && part5.contactTB==3>checked</#if>/>不详
            </span>
            <table id="tb_contactTB_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">被诊断人姓名：</th>
                <td width="30%"><input name="part5.nameOfTB" value="${part5.nameOfTB}" disabled="disabled"/></td>
                <th width="20%">你与他/她的关系：</th>
                <td width="30%"><input name="part5.relationWithTB" value="${part5.relationWithTB}" disabled="disabled"/></td>
              </tr>
              <tr>
                <th>他/她是何时被诊断的：</th>
                <td><input name="part5.dateOfDiagnosis" value="${part5.dateOfDiagnosis}" disabled="disabled" class="Wdate date"/></td>
                <th>他/她是在何处被诊断的：</th>
                <td><input name="part5.diagnosisLocations" value="${part5.diagnosisLocations}" disabled="disabled"/></td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>自1978年以后，你是否接受过输血或血液制品（自然存在于人类血液中的物质，如血小板、第8因子、血浆）</label>
            <span onclick="rotDis('part5.contactBlood', 'checked', [1], 'tb_contactBlood_detail')">
              <input type="radio" name="part5.contactBlood" value="1" <@chk_true val=part5.contactBlood/>/>是
              <input type="radio" name="part5.contactBlood" value="0" <@chk_false val=part5.contactBlood/>/>否
            </span><br />
            <table id="tb_contactBlood_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="30%">你最后一次接受是在什么时间：</th>
                <td width="70%"><input name="part5.dateOfLastCtt" value="${part5.dateOfLastCtt}" disabled="disabled" class="date"/></td>
              </tr>
              <tr>
                <th>你是否患有血友病或出血紊乱症：</th>
                <td>
                  <input type="radio" name="part5.hemophilia" value="1" <@chk_true val=part5.hemophilia/> disabled="disabled"/>是
                  <input type="radio" name="part5.hemophilia" value="0" <@chk_false val=part5.hemophilia/> disabled="disabled"/>否
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th>你是否做过定期检查：</th>
          <td colspan="3">
            <span onclick="rotDis('part5.physicalExam', 'checked', [1], 'examOrg_warp')">
              <input type="radio" name="part5.physicalExam" value="1" <#if part5.physicalExam?? && part5.physicalExam==1>checked</#if>/>是
              <input type="radio" name="part5.physicalExam" value="2" <#if part5.physicalExam?? && part5.physicalExam==2>checked</#if>/>否
              <input type="radio" name="part5.physicalExam" value="3" <#if part5.physicalExam?? && part5.physicalExam==3>checked</#if>/>不详
            </span>
            <span id="examOrg_warp" class="none">
              <label for="part5.examOrg">做体检的机构名称</label><input name="part5.examOrg" value="${part5.examOrg}" disabled="disabled"/>
            </span>
          </td>
        </tr>
        <#else>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你过去是否曾被告知（诊断）患有结核病：</label>
            <input type="radio" name="part5.diagnosedAsTB" value="1"/>是
            <input type="radio" name="part5.diagnosedAsTB" value="2"/>否
            <input type="radio" name="part5.diagnosedAsTB" value="3"/>不详
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>你是否与曾被告知（诊断）患有结核病的任何人有过接触（并非指强阳性结核菌素皮肤实验结果）</label>
            <span onclick="rotDis('part5.contactTB', 'checked', [1], 'tb_contactTB_detail')">
              <input type="radio" name="part5.contactTB" value="1"/>是
              <input type="radio" name="part5.contactTB" value="2"/>否
              <input type="radio" name="part5.contactTB" value="3"/>不详
            </span>
            <table id="tb_contactTB_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="20%">被诊断人姓名：</th>
                <td width="30%"><input name="part5.nameOfTB" disabled="disabled"/></td>
                <th width="20%">你与他/她的关系：</th>
                <td width="30%"><input name="part5.relationWithTB" disabled="disabled"/></td>
              </tr>
              <tr>
                <th>他/她是何时被诊断的：</th>
                <td><input name="part5.dateOfDiagnosis" disabled="disabled" class="Wdate date"/></td>
                <th>他/她是在何处被诊断的：</th>
                <td><input name="part5.diagnosisLocations" disabled="disabled"/></td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th colspan="4" class="left indent2em">
            <label>自1978年以后，你是否接受过输血或血液制品（自然存在于人类血液中的物质，如血小板、第8因子、血浆）</label>
            <span onclick="rotDis('part5.contactBlood', 'checked', [1], 'tb_contactBlood_detail')">
              <input type="radio" name="part5.contactBlood" value="1"/>是
              <input type="radio" name="part5.contactBlood" value="0"/>否
            </span><br />
            <table id="tb_contactBlood_detail" class="none inform" cellspacing="1">
              <tr>
                <th width="30%">你最后一次接受是在什么时间：</th>
                <td width="70%"><input name="part5.dateOfLastCtt" disabled="disabled" class="date"/></td>
              </tr>
              <tr>
                <th>你是否患有血友病或出血紊乱症：</th>
                <td>
                  <input type="radio" name="part5.hemophilia" value="1" disabled="disabled"/>是
                  <input type="radio" name="part5.hemophilia" value="0" disabled="disabled"/>否
                </td>
              </tr>
            </table>
          </th>
        </tr>
        <tr>
          <th>你是否做过定期检查：</th>
          <td colspan="3">
            <span onclick="rotDis('part5.physicalExam', 'checked', [1], 'examOrg_warp')">
              <input type="radio" name="part5.physicalExam" value="1"/>是
              <input type="radio" name="part5.physicalExam" value="2"/>否
              <input type="radio" name="part5.physicalExam" value="3"/>不详
            </span>
            <span id="examOrg_warp" class="none">
              <label for="part5.examOrg">做体检的机构名称</label><input name="part5.examOrg" disabled="disabled"/>
            </span>
          </td>
        </tr>
        </#if>
        <tr>
          <td colspan="4">六、病人病史</td>
        </tr>
        <#if fxpgb.part6??>
        <#assign part6=fxpgb.part6 />
        <tr>
          <td colspan="4"><table class="cmxform" cellspacing="1">
            <tr>
              <th width="15%">哮喘：</th>
              <td width="35%">
                <input type="radio" name="part6.xc" value="1" <#if part6.xc?? && part6.xc==1>checked</#if>/>是
                <input type="radio" name="part6.xc" value="2" <#if part6.xc?? && part6.xc==2>checked</#if>/>否
                <input type="radio" name="part6.xc" value="3" <#if part6.xc?? && part6.xc==3>checked</#if>/>不详
              </td>
              <th width="15%">慢性阻塞性肺病：</th>
              <td width="35%">
                <input type="radio" name="part6.mxzsxfb" value="1" <#if part6.mxzsxfb?? && part6.mxzsxfb==1>checked</#if>/>是
                <input type="radio" name="part6.mxzsxfb" value="2" <#if part6.mxzsxfb?? && part6.mxzsxfb==2>checked</#if>/>否
                <input type="radio" name="part6.mxzsxfb" value="3" <#if part6.mxzsxfb?? && part6.mxzsxfb==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>支气管扩张：</th>
              <td>
                <input type="radio" name="part6.zqgkz" value="1" <#if part6.zqgkz?? && part6.zqgkz==1>checked</#if>/>是
                <input type="radio" name="part6.zqgkz" value="2" <#if part6.zqgkz?? && part6.zqgkz==2>checked</#if>/>否
                <input type="radio" name="part6.zqgkz" value="3" <#if part6.zqgkz?? && part6.zqgkz==3>checked</#if>/>不详
              </td>
              <th>矽肺病：</th>
              <td>
                <input type="radio" name="part6.xfb" value="1" <#if part6.xfb?? && part6.xfb==1>checked</#if>/>是
                <input type="radio" name="part6.xfb" value="2" <#if part6.xfb?? && part6.xfb==2>checked</#if>/>否
                <input type="radio" name="part6.xfb" value="3" <#if part6.xfb?? && part6.xfb==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>结核病（陈旧）：</th>
              <td>
                <input type="radio" name="part6.TB" value="1" <#if part6.TB?? && part6.TB==1>checked</#if>/>是
                <input type="radio" name="part6.TB" value="2" <#if part6.TB?? && part6.TB==2>checked</#if>/>否
                <input type="radio" name="part6.TB" value="3" <#if part6.TB?? && part6.TB==3>checked</#if>/>不详
              </td>
              <th>非典型结核病：</th>
              <td>
                <input type="radio" name="part6.fdxTB" value="1" <#if part6.fdxTB?? && part6.fdxTB==1>checked</#if>/>是
                <input type="radio" name="part6.fdxTB" value="2" <#if part6.fdxTB?? && part6.fdxTB==2>checked</#if>/>否
                <input type="radio" name="part6.fdxTB" value="3" <#if part6.fdxTB?? && part6.fdxTB==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>放疗：</th>
              <td>
                <input type="radio" name="part6.fl" value="1" <#if part6.fl?? && part6.fl==1>checked</#if>/>是
                <input type="radio" name="part6.fl" value="2" <#if part6.fl?? && part6.fl==2>checked</#if>/>否
                <input type="radio" name="part6.fl" value="3" <#if part6.fl?? && part6.fl==3>checked</#if>/>不详
              </td>
              <th>胸壁畸形或外伤：</th>
              <td>
                <input type="radio" name="part6.xbjx" value="1" <#if part6.xbjx?? && part6.xbjx==1>checked</#if>/>是
                <input type="radio" name="part6.xbjx" value="2" <#if part6.xbjx?? && part6.xbjx==2>checked</#if>/>否
                <input type="radio" name="part6.xbjx" value="3" <#if part6.xbjx?? && part6.xbjx==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>糖尿病：</th>
              <td>
                <input type="radio" name="part6.tnb" value="1" <#if part6.tnb?? && part6.tnb==1>checked</#if>/>是
                <input type="radio" name="part6.tnb" value="2" <#if part6.tnb?? && part6.tnb==2>checked</#if>/>否
                <input type="radio" name="part6.tnb" value="3" <#if part6.tnb?? && part6.tnb==3>checked</#if>/>不详
              </td>
              <th>类肉瘤病：</th>
              <td>
                <input type="radio" name="part6.lrlb" value="1" <#if part6.lrlb?? && part6.lrlb==1>checked</#if>/>是
                <input type="radio" name="part6.lrlb" value="2" <#if part6.lrlb?? && part6.lrlb==2>checked</#if>/>否
                <input type="radio" name="part6.lrlb" value="3" <#if part6.lrlb?? && part6.lrlb==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>纤维性囊肿：</th>
              <td>
                <input type="radio" name="part6.xwxzl" value="1" <#if part6.xwxzl?? && part6.xwxzl==1>checked</#if>/>是
                <input type="radio" name="part6.xwxzl" value="2" <#if part6.xwxzl?? && part6.xwxzl==2>checked</#if>/>否
                <input type="radio" name="part6.xwxzl" value="3" <#if part6.xwxzl?? && part6.xwxzl==3>checked</#if>/>不详
              </td>
              <th>结缔组织病：</th>
              <td>
                <input type="radio" name="part6.jdzzb" value="1" <#if part6.jdzzb?? && part6.jdzzb==1>checked</#if>/>是
                <input type="radio" name="part6.jdzzb" value="2" <#if part6.jdzzb?? && part6.jdzzb==2>checked</#if>/>否
                <input type="radio" name="part6.jdzzb" value="3" <#if part6.jdzzb?? && part6.jdzzb==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>胃部手术：</th>
              <td>
                <input type="radio" name="part6.wbss" value="1" <#if part6.wbss?? && part6.wbss==1>checked</#if>/>是
                <input type="radio" name="part6.wbss" value="2" <#if part6.wbss?? && part6.wbss==2>checked</#if>/>否
                <input type="radio" name="part6.wbss" value="3" <#if part6.wbss?? && part6.wbss==3>checked</#if>/>不详
              </td>
              <th>肺癌：</th>
              <td>
                <input type="radio" name="part6.fa" value="1" <#if part6.fa?? && part6.fa==1>checked</#if>/>是
                <input type="radio" name="part6.fa" value="2" <#if part6.fa?? && part6.fa==2>checked</#if>/>否
                <input type="radio" name="part6.fa" value="3" <#if part6.fa?? && part6.fa==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>其他肿瘤：</th>
              <td>
                <input type="radio" name="part6.qtzl" value="1" <#if part6.qtzl?? && part6.qtzl==1>checked</#if>/>是
                <input type="radio" name="part6.qtzl" value="2" <#if part6.qtzl?? && part6.qtzl==2>checked</#if>/>否
                <input type="radio" name="part6.qtzl" value="3" <#if part6.qtzl?? && part6.qtzl==3>checked</#if>/>不详
              </td>
              <th>充血性心衰：</th>
              <td>
                <input type="radio" name="part6.cxxxs" value="1" <#if part6.cxxxs?? && part6.cxxxs==1>checked</#if>/>是
                <input type="radio" name="part6.cxxxs" value="2" <#if part6.cxxxs?? && part6.cxxxs==2>checked</#if>/>否
                <input type="radio" name="part6.cxxxs" value="3" <#if part6.cxxxs?? && part6.cxxxs==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>肾衰：</th>
              <td>
                <input type="radio" name="part6.ss" value="1" <#if part6.ss?? && part6.ss==1>checked</#if>/>是
                <input type="radio" name="part6.ss" value="2" <#if part6.ss?? && part6.ss==2>checked</#if>/>否
                <input type="radio" name="part6.ss" value="3" <#if part6.ss?? && part6.ss==3>checked</#if>/>不详
              </td>
              <th>高血压：</th>
              <td>
                <input type="radio" name="part6.gxy" value="1" <#if part6.gxy?? && part6.gxy==1>checked</#if>/>是
                <input type="radio" name="part6.gxy" value="2" <#if part6.gxy?? && part6.gxy==2>checked</#if>/>否
                <input type="radio" name="part6.gxy" value="3" <#if part6.gxy?? && part6.gxy==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>肝病：</th>
              <td>
                <input type="radio" name="part6.gb" value="1" <#if part6.gb?? && part6.gb==1>checked</#if>/>是
                <input type="radio" name="part6.gb" value="2" <#if part6.gb?? && part6.gb==2>checked</#if>/>否
                <input type="radio" name="part6.gb" value="3" <#if part6.gb?? && part6.gb==3>checked</#if>/>不详
              </td>
              <th>甲型肝炎：</th>
              <td>
                <input type="radio" name="part6.jxgy" value="1" <#if part6.jxgy?? && part6.jxgy==1>checked</#if>/>是
                <input type="radio" name="part6.jxgy" value="2" <#if part6.jxgy?? && part6.jxgy==2>checked</#if>/>否
                <input type="radio" name="part6.jxgy" value="3" <#if part6.jxgy?? && part6.jxgy==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>乙型肝炎：</th>
              <td>
                <input type="radio" name="part6.yxgy" value="1" <#if part6.yxgy?? && part6.yxgy==1>checked</#if>/>是
                <input type="radio" name="part6.yxgy" value="2" <#if part6.yxgy?? && part6.yxgy==2>checked</#if>/>否
                <input type="radio" name="part6.yxgy" value="3" <#if part6.yxgy?? && part6.yxgy==3>checked</#if>/>不详
              </td>
              <th>丙型肝炎：</th>
              <td>
                <input type="radio" name="part6.bxgy" value="1" <#if part6.bxgy?? && part6.bxgy==1>checked</#if>/>是
                <input type="radio" name="part6.bxgy" value="2" <#if part6.bxgy?? && part6.bxgy==2>checked</#if>/>否
                <input type="radio" name="part6.bxgy" value="3" <#if part6.bxgy?? && part6.bxgy==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>梅毒：</th>
              <td>
                <input type="radio" name="part6.md" value="1" <#if part6.md?? && part6.md==1>checked</#if>/>是
                <input type="radio" name="part6.md" value="2" <#if part6.md?? && part6.md==2>checked</#if>/>否
                <input type="radio" name="part6.md" value="3" <#if part6.md?? && part6.md==3>checked</#if>/>不详
              </td>
              <th>淋病：</th>
              <td>
                <input type="radio" name="part6.lb" value="1" <#if part6.lb?? && part6.lb==1>checked</#if>/>是
                <input type="radio" name="part6.lb" value="2" <#if part6.lb?? && part6.lb==2>checked</#if>/>否
                <input type="radio" name="part6.lb" value="3" <#if part6.lb?? && part6.lb==3>checked</#if>/>不详
              </td>
            </tr>
            <tr>
              <th>免疫抑制疗法：</th>
              <td>
                <input type="radio" name="part6.myyzlf" value="1" <#if part6.md?? && part6.md==1>checked</#if>/>是
                <input type="radio" name="part6.myyzlf" value="2" <#if part6.md?? && part6.md==2>checked</#if>/>否
                <input type="radio" name="part6.myyzlf" value="3" <#if part6.md?? && part6.md==3>checked</#if>/>不详
              </td>
              <th>整形手术：</th>
              <td>
                <span onclick="rotDis('part6.zxss', 'checked', [1], 'zxsslx_warp')">
                  <input type="radio" name="part6.zxss" value="1" <#if part6.zxss?? && part6.zxss==1>checked</#if>/>是
                  <input type="radio" name="part6.zxss" value="2" <#if part6.zxss?? && part6.zxss==2>checked</#if>/>否
                  <input type="radio" name="part6.zxss" value="3" <#if part6.zxss?? && part6.zxss==3>checked</#if>/>不详
                </span>
                <span id="zxsslx_warp" class="none">
                  <label for="part6.zxsslx">类型</label><input name="part6.zxsslx" value="${part6.zxsslx}" disabled="disabled"/>
                </span>
              </td>
            </tr>
            <tr>
              <th>其他手术：</th>
              <td>
                <span onclick="rotDis('part6.qtss', 'checked', [1], 'qtsslx_warp')">
                  <input type="radio" name="part6.qtss" value="1" <#if part6.qtss?? && part6.qtss==1>checked</#if>/>是
                  <input type="radio" name="part6.qtss" value="2" <#if part6.qtss?? && part6.qtss==2>checked</#if>/>否
                  <input type="radio" name="part6.qtss" value="3" <#if part6.qtss?? && part6.qtss==3>checked</#if>/>不详
                </span>
                <span id="qtsslx_warp" class="none">
                  <label for="part6.qtsslx">类型</label><input name="part6.qtsslx" value="${part6.qtsslx}" disabled="disabled"/>
                </span>
              </td>
              <th>严重外伤：</th>
              <td>
                <span onclick="rotDis('part6.ws', 'checked', [1], 'wslx_warp')">
                  <input type="radio" name="part6.ws" value="1" <#if part6.ws?? && part6.ws==1>checked</#if>/>是
                  <input type="radio" name="part6.ws" value="2" <#if part6.ws?? && part6.ws==2>checked</#if>/>否
                  <input type="radio" name="part6.ws" value="3" <#if part6.ws?? && part6.ws==3>checked</#if>/>不详
                </span>
                <span id="wslx_warp" class="none">
                  <label for="part6.wslx">类型</label><input name="part6.wslx" value="${part6.wslx}" disabled="disabled"/>
                </span>
              </td>
            </tr>
            <tr>
              <th>其他：</th>
              <td colspan="3">
                <input name="part6.qt" value="${part6.qt}"/>
              </td>
            </tr>
          </table></td>
        </tr>
        <#else>
        <tr>
          <td colspan="4"><table class="cmxform" cellspacing="1">
            <tr>
              <th width="15%">哮喘：</th>
              <td width="35%">
                <input type="radio" name="part6.xc" value="1"/>是
                <input type="radio" name="part6.xc" value="2"/>否
                <input type="radio" name="part6.xc" value="3"/>不详
              </td>
              <th width="15%">慢性阻塞性肺病：</th>
              <td width="35%">
                <input type="radio" name="part6.mxzsxfb" value="1"/>是
                <input type="radio" name="part6.mxzsxfb" value="2"/>否
                <input type="radio" name="part6.mxzsxfb" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>支气管扩张：</th>
              <td>
                <input type="radio" name="part6.zqgkz" value="1"/>是
                <input type="radio" name="part6.zqgkz" value="2"/>否
                <input type="radio" name="part6.zqgkz" value="3"/>不详
              </td>
              <th>矽肺病：</th>
              <td>
                <input type="radio" name="part6.xfb" value="1"/>是
                <input type="radio" name="part6.xfb" value="2"/>否
                <input type="radio" name="part6.xfb" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>结核病（陈旧）：</th>
              <td>
                <input type="radio" name="part6.TB" value="1"/>是
                <input type="radio" name="part6.TB" value="2"/>否
                <input type="radio" name="part6.TB" value="3"/>不详
              </td>
              <th>非典型结核病：</th>
              <td>
                <input type="radio" name="part6.fdxTB" value="1"/>是
                <input type="radio" name="part6.fdxTB" value="2"/>否
                <input type="radio" name="part6.fdxTB" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>放疗：</th>
              <td>
                <input type="radio" name="part6.fl" value="1"/>是
                <input type="radio" name="part6.fl" value="2"/>否
                <input type="radio" name="part6.fl" value="3"/>不详
              </td>
              <th>胸壁畸形或外伤：</th>
              <td>
                <input type="radio" name="part6.xbjx" value="1"/>是
                <input type="radio" name="part6.xbjx" value="2"/>否
                <input type="radio" name="part6.xbjx" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>糖尿病：</th>
              <td>
                <input type="radio" name="part6.tnb" value="1"/>是
                <input type="radio" name="part6.tnb" value="2"/>否
                <input type="radio" name="part6.tnb" value="3"/>不详
              </td>
              <th>类肉瘤病：</th>
              <td>
                <input type="radio" name="part6.lrlb" value="1"/>是
                <input type="radio" name="part6.lrlb" value="2"/>否
                <input type="radio" name="part6.lrlb" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>纤维性囊肿：</th>
              <td>
                <input type="radio" name="part6.xwxzl" value="1"/>是
                <input type="radio" name="part6.xwxzl" value="2"/>否
                <input type="radio" name="part6.xwxzl" value="3"/>不详
              </td>
              <th>结缔组织病：</th>
              <td>
                <input type="radio" name="part6.jdzzb" value="1"/>是
                <input type="radio" name="part6.jdzzb" value="2"/>否
                <input type="radio" name="part6.jdzzb" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>胃部手术：</th>
              <td>
                <input type="radio" name="part6.wbss" value="1"/>是
                <input type="radio" name="part6.wbss" value="2"/>否
                <input type="radio" name="part6.wbss" value="3"/>不详
              </td>
              <th>肺癌：</th>
              <td>
                <input type="radio" name="part6.fa" value="1"/>是
                <input type="radio" name="part6.fa" value="2"/>否
                <input type="radio" name="part6.fa" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>其他肿瘤：</th>
              <td>
                <input type="radio" name="part6.qtzl" value="1"/>是
                <input type="radio" name="part6.qtzl" value="2"/>否
                <input type="radio" name="part6.qtzl" value="3"/>不详
              </td>
              <th>充血性心衰：</th>
              <td>
                <input type="radio" name="part6.cxxxs" value="1"/>是
                <input type="radio" name="part6.cxxxs" value="2"/>否
                <input type="radio" name="part6.cxxxs" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>肾衰：</th>
              <td>
                <input type="radio" name="part6.ss" value="1"/>是
                <input type="radio" name="part6.ss" value="2"/>否
                <input type="radio" name="part6.ss" value="3"/>不详
              </td>
              <th>高血压：</th>
              <td>
                <input type="radio" name="part6.gxy" value="1"/>是
                <input type="radio" name="part6.gxy" value="2"/>否
                <input type="radio" name="part6.gxy" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>肝病：</th>
              <td>
                <input type="radio" name="part6.gb" value="1"/>是
                <input type="radio" name="part6.gb" value="2"/>否
                <input type="radio" name="part6.gb" value="3"/>不详
              </td>
              <th>甲型肝炎：</th>
              <td>
                <input type="radio" name="part6.jxgy" value="1"/>是
                <input type="radio" name="part6.jxgy" value="2"/>否
                <input type="radio" name="part6.jxgy" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>乙型肝炎：</th>
              <td>
                <input type="radio" name="part6.yxgy" value="1"/>是
                <input type="radio" name="part6.yxgy" value="2"/>否
                <input type="radio" name="part6.yxgy" value="3"/>不详
              </td>
              <th>丙型肝炎：</th>
              <td>
                <input type="radio" name="part6.bxgy" value="1"/>是
                <input type="radio" name="part6.bxgy" value="2"/>否
                <input type="radio" name="part6.bxgy" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>梅毒：</th>
              <td>
                <input type="radio" name="part6.md" value="1"/>是
                <input type="radio" name="part6.md" value="2"/>否
                <input type="radio" name="part6.md" value="3"/>不详
              </td>
              <th>淋病：</th>
              <td>
                <input type="radio" name="part6.lb" value="1"/>是
                <input type="radio" name="part6.lb" value="2"/>否
                <input type="radio" name="part6.lb" value="3"/>不详
              </td>
            </tr>
            <tr>
              <th>免疫抑制疗法：</th>
              <td>
                <input type="radio" name="part6.myyzlf" value="1"/>是
                <input type="radio" name="part6.myyzlf" value="2"/>否
                <input type="radio" name="part6.myyzlf" value="3"/>不详
              </td>
              <th>整形手术：</th>
              <td>
                <span onclick="rotDis('part6.zxss', 'checked', [1], 'zxsslx_warp')">
                  <input type="radio" name="part6.zxss" value="1"/>是
                  <input type="radio" name="part6.zxss" value="2"/>否
                  <input type="radio" name="part6.zxss" value="3"/>不详
                </span>
                <span id="zxsslx_warp" class="none">
                  <label for="part6.zxsslx">类型</label><input name="part6.zxsslx" disabled="disabled"/>
                </span>
              </td>
            </tr>
            <tr>
              <th>其他手术：</th>
              <td>
                <span onclick="rotDis('part6.qtss', 'checked', [1], 'qtsslx_warp')">
                  <input type="radio" name="part6.qtss" value="1"/>是
                  <input type="radio" name="part6.qtss" value="2"/>否
                  <input type="radio" name="part6.qtss" value="3"/>不详
                </span>
                <span id="qtsslx_warp" class="none">
                  <label for="part6.qtsslx">类型</label><input name="part6.qtsslx" disabled="disabled"/>
                </span>
              </td>
              <th>严重外伤：</th>
              <td>
                <span onclick="rotDis('part6.ws', 'checked', [1], 'wslx_warp')">
                  <input type="radio" name="part6.ws" value="1"/>是
                  <input type="radio" name="part6.ws" value="2"/>否
                  <input type="radio" name="part6.ws" value="3"/>不详
                </span>
                <span id="wslx_warp" class="none">
                  <label for="part6.wslx">类型</label><input name="part6.wslx" disabled="disabled"/>
                </span>
              </td>
            </tr>
            <tr>
              <th>其他：</th>
              <td colspan="3">
                <input name="part6.qt"/>
              </td>
            </tr>
          </table></td>
        </tr>
        </#if>
        <tfoot>
          <tr>
            <td colspan="4">
              <input type="hidden" name="curStep" value="fxpgb"/>
              <input type="hidden" name="chain" value="${chain}"/>
              <input type="hidden" id="action" name="action" value="forward"/>
              <button type="button" class="back" onclick="$('#action').val('reverse');$('#fxpgbForm').submit()"></button>&nbsp;&nbsp;&nbsp;
              <button type="button" class="save" onclick="$('#fxpgbForm').submit()"></button>&nbsp;&nbsp;&nbsp;
              <button type="button" class="submit" onclick="if(confirm('你确认提交吗，提交后不再允许修改？')){$('#action').val('submit');$('#fxpgbForm').submit();}else{return false;}"></button>
            </td>
          </tr>
        </tfoot>
      </table>
    </form>
  </body>
</html>
